WIHS VIROLOGIC REBOUND AND RESISTANCE STUDY
TELEPHONE INTERVIEW FOR MEDICAL PROVIDERS
VRS 6
A1. PARTICIPANT ID: |__|- |__|__| - |__|__|__|__| - |__|
A2. WIHS STUDY VISIT #: ___ ___ A2a. CORE VISIT……………….1
3 MONTH VRS VISIT….…2
A3. FORM VERSION: 1 0 / 0 1 / 0 0 b
M M D D Y Y
A4. DATE OF INTERVIEW: / /
M M D D Y Y
A5. INTERVIEWER’S INITIALS:
THIS FORM SHOULD ONLY BE COMPLETED IF INDICATED ON VRS 5.
A6. DATE RELEASE FAXED: / /
(To providers office) M M D D Y Y
A7. DATE OF 1st ATTEMPT : / /
M M D D Y Y
A8. DATE OF 2nd ATTEMPT: / /
M M D D Y Y
A9. DATE OF 3rd ATTEMPT : / /
M M D D Y Y
Hi, my name is _________ and I'm with the Women's Interagency HIV study. Dr. (NAME PI FROM SITE)
from (NAME OF HOSPITAL OR INSTITUTION) is doing a study on viral rebound and resistance to anti-
retroviral medications and would like to get some information on (PARTICIPANT’S NAME) anti-retroviral
medications. Do you have 5 minutes to talk with me?
B1. Since (DATE 6 MONTHS PRIOR TO REPORT), did you prescribe different or new anti-
retroviral medications for this patient or discontinue any anti-retroviral medications?
YES…………………………..1
NO……………………………2 (STOP HERE)
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VRS 6: Telephone Interview for Medical Providers – 10/01/00b
Page 1 of 5
WIHS ID#
B. Which anti-retroviral medications did you start in the last 6 months? Please list the name of each medication, the dosage, the
date, and the main reason for the change in prescription.
Which anti-retroviral medications did you discontinue in the last 6 months? Please list the name of each medication, the date
and the main reason for the change in prescription.
Name of medication Dosage of new Date medication What was the main reason for the change in prescription:
medication stopped or started CIRCLE ONLY ONE.
2 c. d. e. Medication is easier to take……………………… 1
a. __ __ __ __ mg * __ __/__ __/__ __ Patient is failing therapy ………………………… 2
*LEAVE BLANK FOR M M D D Y Y CIRCLE ALL REASONS THAT APPLY BELOW
MEDS COMBINING YES NO
b. 2 OR MORE Patient's CD4 count went down……..1…….2
Stopped….1 (GO TO d) SUBSTANCES Patient's viral load went up…….……1…….2
Clinical progression………………….1…….2 (GO TO 3a)
Started……2 QDAY……1 To alleviate side effects……….……………………….. 3
QHS………2 Started interacting medication…….…………………… 4
BID……….3 Patient request……..………………….………………. 5
TID……….4 To change levels of other drugs………….……………. 6
Q 12 h…….5 Patient Non-Compliance………………………………. 7
Q 8 h………6 Other……………………………………….………….. 8
(Specify:______________________________)
3 c. d. e. Medication is easier to take……………………… 1
a. __ __ __ __ mg * __ __/__ __/__ __ Patient is failing therapy ………………………… 2
*LEAVE BLANK FOR M M D D Y Y CIRCLE ALL REASONS THAT APPLY BELOW
MEDS COMBINING YES NO
b. 2 OR MORE Patient's CD4 count went down……..1…….2
Stopped….1 (GO TO d) SUBSTANCES Patient's viral load went up…….……1…….2
Clinical progression………………….1…….2(GO TO 4a)
Started……2 QDAY……1 To alleviate side effects……….……………………….. 3
QHS………2 Started interacting medication…….…………………… 4
BID……….3 Patient request……..………………….………………. 5
TID……….4 To change levels of other drugs………….……………. 6
Q 12 h…….5 Patient Non-Compliance………………………………. 7
Q 8 h………6 Other……………………………………….………….. 8
(Specify:______________________________)
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VRS 6: Telephone Interview for Medical Providers – 10/01/00b
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WIHS ID#
Name of medication Dosage of new Date medication What was the main reason for the change in prescription:
medication stopped or started CIRCLE ONLY ONE.
4 c. d. e. Medication is easier to take……………………… 1
a. __ __ __ __ mg * __ __/__ __/__ __ Patient is failing therapy ………………………… 2
*LEAVE BLANK FOR M M D D Y Y CIRCLE ALL REASONS THAT APPLY BELOW
MEDS COMBINING YES NO
b. 2 OR MORE Patient's CD4 count went down……..1…….2
Stopped….1 (GO TO d) SUBSTANCES Patient's viral load went up…….……1…….2
Clinical progression………………….1…….2(GO TO 5a)
Started……2 QDAY……1 To alleviate side effects……….……………………….. 3
QHS………2 Started interacting medication…….…………………… 4
BID……….3 Patient request……..………………….………………. 5
TID……….4 To change levels of other drugs………….……………. 6
Q 12 h…….5 Patient Non-Compliance………………………………. 7
Q 8 h………6 Other……………………………………….………….. 8
(Specify:______________________________)
5 c. d. e. Medication is easier to take……………………… 1
a. __ __ __ __ mg * __ __/__ __/__ __ Patient is failing therapy ………………………… 2
*LEAVE BLANK FOR M M D D Y Y CIRCLE ALL REASONS THAT APPLY BELOW
MEDS COMBINING YES NO
b. 2 OR MORE Patient's CD4 count went down……..1…….2
Stopped….1 (GO TO d) SUBSTANCES Patient's viral load went up…….……1…….2
Clinical progression………………….1…….2(GO TO 6a)
Started……2 QDAY……1 To alleviate side effects……….……………………….. 3
QHS………2 Started interacting medication…….…………………… 4
BID……….3 Patient request……..………………….………………. 5
TID……….4 To change levels of other drugs………….……………. 6
Q 12 h…….5 Patient Non-Compliance………………………………. 7
Q 8 h………6 Other……………………………………….………….. 8
(Specify:______________________________)
_________________________________________________________________________________________________________
VRS 6: Telephone Interview for Medical Providers – 10/01/00b
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WIHS ID#
Name of medication Dosage of new Date medication What was the main reason for the change in prescription:
medication stopped or started CIRCLE ONLY ONE.
6 c. d. e. Medication is easier to take……………………… 1
a. __ __ __ __ mg * __ __/__ __/__ __ Patient is failing therapy ………………………… 2
*LEAVE BLANK FOR M M D D Y Y CIRCLE ALL REASONS THAT APPLY BELOW
MEDS COMBINING YES NO
b. 2 OR MORE Patient's CD4 count went down……..1…….2
Stopped….1 (GO TO d) SUBSTANCES Patient's viral load went up…….……1…….2
Clinical progression………………….1…….2(GO TO 7a)
Started……2 QDAY……1 To alleviate side effects……….……………………….. 3
QHS………2 Started interacting medication…….…………………… 4
BID……….3 Patient request……..………………….………………. 5
TID……….4 To change levels of other drugs………….……………. 6
Q 12 h…….5 Patient Non-Compliance………………………………. 7
Q 8 h………6 Other……………………………………….………….. 8
(Specify:______________________________)
7 c. d. e. Medication is easier to take……………………… 1
a. __ __ __ __ mg * __ __/__ __/__ __ Patient is failing therapy ………………………… 2
*LEAVE BLANK FOR M M D D Y Y CIRCLE ALL REASONS THAT APPLY BELOW
MEDS COMBINING YES NO
b. 2 OR MORE Patient's CD4 count went down……..1…….2
Stopped….1 (GO TO d) SUBSTANCES Patient's viral load went up…….……1…….2
Clinical progression………………….1…….2(GO TO 8a)
Started……2 QDAY……1 To alleviate side effects……….……………………….. 3
QHS………2 Started interacting medication…….…………………… 4
BID……….3 Patient request……..………………….………………. 5
TID……….4 To change levels of other drugs………….……………. 6
Q 12 h…….5 Patient Non-Compliance………………………………. 7
Q 8 h………6 Other……………………………………….………….. 8
(Specify:______________________________)
_________________________________________________________________________________________________________
VRS 6: Telephone Interview for Medical Providers – 10/01/00b
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WIHS ID#
Name of medication Dosage of new Date medication What was the main reason for the change in prescription:
medication stopped or started CIRCLE ONLY ONE.
8 c. d. e. Medication is easier to take……………………… 1
a. __ __ __ __ mg * __ __/__ __/__ __ Patient is failing therapy ………………………… 2
*LEAVE BLANK FOR M M D D Y Y CIRCLE ALL REASONS THAT APPLY BELOW
MEDS COMBINING YES NO
b. 2 OR MORE Patient's CD4 count went down……..1…….2
Stopped….1 (GO TO d) SUBSTANCES Patient's viral load went up…….……1…….2
Clinical progression………………….1…….2(GO TO 9a)
Started……2 QDAY……1 To alleviate side effects……….……………………….. 3
QHS………2 Started interacting medication…….…………………… 4
BID……….3 Patient request……..………………….………………. 5
TID……….4 To change levels of other drugs………….……………. 6
Q 12 h…….5 Patient Non-Compliance………………………………. 7
Q 8 h………6 Other……………………………………….………….. 8
(Specify:______________________________)
9 c. d. e. Medication is easier to take……………………… 1
a. __ __ __ __ mg * __ __/__ __/__ __ Patient is failing therapy ………………………… 2
*LEAVE BLANK FOR M M D D Y Y CIRCLE ALL REASONS THAT APPLY BELOW
MEDS COMBINING YES NO
b. 2 OR MORE Patient's CD4 count went down……..1…….2
Stopped….1 (GO TO d) SUBSTANCES Patient's viral load went up…….……1…….2
Clinical progression………………….1…….2
Started……2 QDAY……1 To alleviate side effects……….……………………….. 3
QHS………2 Started interacting medication…….…………………… 4
BID……….3 Patient request……..………………….………………. 5
TID……….4 To change levels of other drugs………….……………. 6
Q 12 h…….5 Patient Non-Compliance………………………………. 7
Q 8 h………6 Other……………………………………….………….. 8
(Specify:______________________________)
_________________________________________________________________________________________________________
VRS 6: Telephone Interview for Medical Providers – 10/01/00b
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